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April 3, 2020

COVID 19 Infection ControlAssisted Living and Homebased Residential Groups

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COVID 19 Infection ControlAssisted Living and Homebased Residential Groups

Jennifer Spivey MSN, RN, CNOR, CIC, FAPICInfection Preventionist Infectious Disease Epidemiology Resource Center

March 31, 2020

https://ihan-in.org/

Sign up for

Indiana Health Alert Network

COVID IP Toolkit• Developed on 3/24/20 for Long term care, retirement

communities, independent living facilities.

• Updates get posted on the ISDH Website.

– ISDH nurse surveyors took this to all 737 LTC across the state in 3

day period last week!

– Assessed readiness with administrators and entrance IC measures.

• Tool kit is applicable in behavioral health, homeless

shelters and can be adapted to other facilities.

– Basic Infection Control practices remain consistent

– ISDH COVID Website - https://coronavirus.in.gov/

– COVID IP TOOLKIT- https://coronavirus.in.gov/files/COVID-

19%20IP%20Toolkit%20ISDH_3-29-2020.pdf

COVID-19 Toolkit for Long

Term Care

• 67-page document- includes all printed out list N cleaning products for facilities.

• Guidance for preparedness and implementation of recommendations.

• Outbreak Respiratory Surveillance tools.

• HCW guidance for COVID19.

• Guidance for out of hospital mitigation.

• Long term care Newsletters- ISDH site

https://www.in.gov/isdh/24526.htm

5

Home Care Infection Control

6

Published March 30, 2020 on

https://coronavirus.in.gov/

Three pages in length

COVID IP Toolkit benefits

• Long term care

• Residential care/ Assisted Living

• Memory care

• Group homes

• Homeless shelters- hotel set ups

• Correctional facilities

• Behavioral health settings – although they are surveyed under acute care

regulations they are more like long term care due to their length of stay for patients and physical layouts with community rooms

7

Strike teams

8

• To schedule a LTC Strike team– striketeamrequest@isdh.in.gov

• Team has grown from 2 teams to 5 teams by region in 2 weeks. This

process is very fluid right now and ever changing…..

• They preform testing in LTC buildings for symptomatic HCW

and residents.

Facilities that test positive for resident and HCW are

visited again for testing as the exposures are considered

positive.

Infection Control follow up call from the ISDH IP post

strike team visit to follow up.

• Initial teams went out with LTC nurse surveyor to access

Infection control concerns and guidance for cohorting.

Nurse surveyors used for IC follow-up.

• Teams are growing- 5 breaking up to 10 for testing, planning drive

regional drive through clinics for HCW to support Lilly.

People aged 65 years and older

People who live in a nursing home or long-term care facility

Other high-risk conditions could include:

People with chronic lung disease or moderate to severe asthma

People who have serious heart conditions

People who are immunocompromised including cancer treatment

People of any age with severe obesity (body mass index [BMI] >40) or certain

underlying medical conditions, particularly if not well controlled, such as

those with diabetes, renal failure, or liver disease might also be at risk

People who are pregnant should be monitored since they are known to be at

risk with severe viral illness, however, to date data on COVID-19 has not

shown increased risk

Higher risk for severe illness

Based on currently available CDC information and clinical

expertise, older adults and people of any age who have

serious underlying medical conditions might be at higher risk

for severe illness from COVID-19.

9

Focus on Resident care

• CMS has lifted a lot of regulations and guidance to release

residents back into LTC and rehabs, etc. without penalty during

this pandemic.

• ISDH does not have specific waivers for some rules, i. e. fire

drills, water temp testing, routine monthly physicals or testing.

• Anything that increases movement or introduces outside

sources into you building is an infection control risk and is

discouraged for resident protection.

• We want you to focus on resident care and we have no intent

to hold facilities to rules that could not or should not have been

met during this time.

10

Updated daily at 10 a.m.

https://coronavirus.in.gov/2393.htm

COVID-19 Dashboard

Added Demographics

38.5% of positives

are > 60 yr. old

87.2% of deaths

are > 60 yr. old

LTC Outbreak Infection

Prevention Matters

CDC updated Clinical Guidance

March 30

• incubation period for COVID-19 is thought to extend to 14 days, with a

median time of 4-5 days from exposure to symptoms onset.1-3

• One study reported that 97.5% of persons with COVID-19 who develop

symptoms will do so within 11.5 days of SARS-CoV-2 infection.

• https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-

management-patients.html

Clinical Presentation

The signs and symptoms of COVID-19 present at illness onset

vary, but over the course of the disease, most persons with COVID-

19 will experience the following1,4-9:

• Fever (83–99%)

• Cough (59–82%)

• Fatigue (44–70%)

• Anorexia (40–84%)

• Shortness of breath (31–40%)

• Sputum production (28–33%)

• Myalgias (11–35%)

The elderly

• Atypical presentations have been described and older adults

and persons with medical comorbidities may have delayed

presentation of fever and respiratory symptoms.10,11

• In one study of 1,099 hospitalized patients, fever was present in

only 44% at hospital admission but later developed in 89%

during hospitalization.1

• Headache, confusion, rhinorrhea, sore throat, hemoptysis,

vomiting, and diarrhea have been reported but are less common

(<10%).1,4-6

• Some persons with COVID-19 have experienced

gastrointestinal symptoms such as diarrhea and nausea prior to

developing fever and lower respiratory tract signs and

symptoms.9

Early Release of MMWR- March 27, 2020

Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing

Facility — King County, Washington, March 2020

Top 10 items for Breaking the Chain for

COVID transmission1. Visitor and HCW daily monitoring at

entrances, symptoms and temps

2. Hand Hygiene at point of care- ABHR and frequent hand washing

3. Enhanced environmental cleaning and disinfection with appropriate agents

4. Standard Precautions- Universal masking for direct care HCW

5. Contact-Droplet Precautions for resident symptomatic or COVID positive

6. PPE Guidance- prepare for reuse

7. Resident placement in the facility

• Cohorting symptomatic or COVID positive resident

• Cohort residential, LTC and memory care if possible

• Cohorting staff and equipment for symptomatic or COVID positive resident

8. Health Care Worker protection and guidance

9. Supplies and Food Safety

10. Transfer Communication to Acute Care

Circle the Wagons#1• Visitor Restrictions- visitors

and healthcare workers (HCW)

are the most likely sources of

introduction of COVID-19 into a

facility.

• CDC recommends aggressive

visitor restrictions and enforcing

sick leave policies for ill HCW as

COVID-19 is identified in a

community or facility.

• Mask all HCW that are ill and

remove from duty immediately.

• Screen HCW and visitors that

must come to the building for

symptoms and temps daily.

Look for protection, get defensive, get ready for

an attack; from the old west where

the pioneers would circle their wagons for

protection.

Hand Hygiene (HH)

• Preferred method of hygiene is ABHR• Use HW if hands feel tacky after

multiple uses of hand sanitizer use soap and water.

• ABHR should be greater than 60% ethanol or 70% of isopropanol as preferred form of HH.

Use Handwashing when:• Hands are visibly soiled• After providing resident care for

tolieting • After using the restroom• Before and after eating• After coughing or sneezing• All other times use ABHR

Evidence Based

Strategies

CDC

Recommendations

#2

Hand Hygiene incudes Glove hygiene means

NOT wearing gloves everywhere when they

are contaminated!

Gloves

Glove Hygiene: Perform HH before donning gloves.

• Use non-sterile gloves upon entry into the resident room

for direct care area.

– Change gloves if they become torn or heavily

contaminated.

– Remove and discard gloves when leaving the resident

room or care area.

• Immediately perform hand hygiene after removal of

gloves.

Environmental Cleaning

#3

• Increase Environmental

cleaning on all high

touch surfaces in

building with approved

disinfectants

• Use approved Cleaning

agents from List N:

https://www.epa.gov/pesti

cide-registration/list-n-

disinfectants-use-against-

sars-cov-2

• For shortage of approved

disinfecting solutions:

Bleach 1:10 mixture (must

be changed and remixed

every 24 hours) which is 1

½ cups of bleach per

gallon.

Cleaning is not the same as Disinfection

Cleaning refers to the removal of dirt and

impurities, including germs, from surfaces.

Cleaning alone does not kill germs. But by

removing the germs, it decreases their number

and therefore any risk of spreading infection.

Disinfecting works by using chemicals to

kill germs on surfaces. This process does not

necessarily clean dirty surfaces or remove

germs. But killing germs remaining on a

surface after cleaning further reduces any risk

of spreading infection.

Wear disposable gloves to clean

and disinfect and use HH after

removal of gloves!

– It is recommended to close off areas used by the ill persons and

wait as long as practical before beginning cleaning and

disinfection to minimize potential for exposure to respiratory

droplets. Open outside doors and windows to increase air

circulation in the area. If possible, wait up to 24 hours before

beginning cleaning and disinfection.

– In areas where ill persons are being housed in isolation,

follow Interim Guidance for Environmental Cleaning and Disinfection

for U.S. Households with Suspected or Confirmed Coronavirus

Disease 2019.

– This includes focusing on cleaning and disinfecting common

areas where staff/others providing services may come into

contact with ill persons, but reducing cleaning and disinfection

of bedrooms/bathrooms used by ill persons to as needed.

– In areas where ill persons have visited or used, continue routine

cleaning and disinfection as in this guidance.

Environmental Cleaning and Disinfection

Recommendations

• Two recent studies have investigated how long coronaviruses survive

on different surfaces. The research looked at a number of different

viruses including SARS-CoV-2 – the coronavirus that has caused

COVID-19. And it found that the survival times varied according to the

type of surfaces.

• The virus survived for longest on stainless steel and plastic – for up

to nine days. The shortest survival times of one day was for paper and

cardboard.

– Air 3 hours- So by opening the window, you can remove and

disperse the droplets and reduce the amount of virus in the air –

which will reduce the risk of infection for others.

– Cardboard 24 hours

– Plastic > 72 hours

– Stainless Steel 48 hoursResources:

• https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763473?resultClick=1&utm_source=Trend

MD&utm_medium=cpc&utm_campaign=JAMA_Network_Open_TrendMD_1

• file:///K:/Outbreak/AR-HAI%20folder/Infection%20Prevention_JKS/COVID-

19%20IP%20Tools/Disinfectants%20and%20Cleaning/surfaces%20virus%20lives%20on%20NEJM.pdf

Surfaces

Cleaning Products homebased

• For shortage of approved

disinfecting solutions: Bleach 1:10

mixture (must be changed and remixed

every 24 hours) which is 1 ½ cups of

bleach per gallon

• Soap and Water- first line of defense

• Bleach- The active ingredient in bleach – sodium hypochlorite –

is very effective at killing the virus. Make sure you leave the bleach

to work for 10-15 minutes then give the surface a wipe with a clean

cloth.

• Alcohol- ethanol- 70% kills in as little as 30 seconds.

• It is not yet clear how long the virus can survive

on clothing:

– So far, there aren't scientific findings on how long the

virus can live on fabric. But fabrics are generally

porous — as is cardboard, which has been tested.

And a recent study did find that the virus can live on

cardboard for up to 24 hours.

– We do recommend HCW to change their scrubs and

clothing at work and take them home in a bag to put

in the washer and dryer.

Coronavirus on clothing

For clothing, towels, linens and other items of COVID resident:

• Wear disposable gloves.

• Wash hands with soap and water as soon as you remove the gloves.

• Do not shake dirty laundry.

• Launder items according to the manufacturer’s instructions. Use the

warmest appropriate water setting and dry items completely.

• Dirty laundry from a sick person can be washed with other people’s

items.

• Clean and disinfect clothes hampers according to guidance above for

surfaces

Laundry

• Keep washing your

hands!

• Use 60% or higher hand

sanitizer

• Do not touch your T

zone- nose, face, mouth

• Dust off the bleach

wipes

• Open a window to let in

the spring air.

The Bottom line

Standard Precautions

Assumes blood and body fluid

of ANY resident or patient could

be infectious.

Wear gloves, gowns, masks,

and eyewear at the right times.

Decisions about PPE use

determined by type of clinical

interaction with resident or

patient.

#4

Transmission-based Precautions#5

Contact- Droplet Precautions: Always wear a mask,

eye protection, gown and gloves for

direct resident care of symptomatic or COVID

confirmed.

* Droplet precaution facility wide with mask for all

buildings with ongoing transmission.

Minimize Transmission Place a sign on the door indicating Droplet- Contact

Precautions.

• Single resident room or apartment placement to minimize

exposures and adherence to PPE and HH compliance.

– Residents wear masks if respiratory issues while direct care giver in

the room

– Memory care unit- monitor residents daily for signs and symptoms

– Dedicated staff for these residents

• Minimize resident’s movement around the building- confined

to room or as in memory care consider placement in single

room with dedicated staff to care for this resident.

• Cohort staff and equipment for COVID-19 residents to

minimize transmission in the building

PPE

• Recommend symptomatic residents be immediately given a mask.

• Providers should suspect COVID-19 on all symptomatic residents and wear a mask.

• Direct care givers should use universal mask in group homes, LTC, residential and assisted living, et. al.

– N95 or equivalent is not necessary unless performing an aerosol producing procedure.

#6

Mask Conservation

All facilities should require those involved

in direct patient care to wear a mask during

their entire shift if symptomatic or COVID

residents are in the home.

https://www.cdc.gov/coronavirus/2019-

ncov/hcp/ppe-strategy/face-masks.html

Gown Conservation

Gown Conservation: If there are shortages of gowns, they should be

prioritized for:

• aerosol-generating procedures

• care activities where splashes and sprays are anticipated

• High-contact patient care activities that provide opportunities for

transfer of pathogens to the hands and clothing of HCP

• Examples include:

• dressing • changing linens

• bathing/showering • wound care

• providing hygiene • transferring

• changing briefs or assisting • device care use

with toileting

PPE Conservation• Extended use if limited access to facemasks:

– Consider having HCP remove only gloves and gowns

(if used) and perform hand hygiene between patients

with the same diagnosis (e.g., confirmed COVID-19)

while continuing to wear the same eye protection and

respirator or facemask

– Risk of transmission from eye protection and

facemasks during extended use is expected to be

very low.

– Use paper bag or Ziploc to store mask in between

use, do not touch front of mask but only by strings or

elastic, perform HH after doffing.

– Can re-use gowns at last resort, but do not

wear same gown all over the facility.

Preservation of protective

eyewear/goggles or face shield

– Do not touch eye or face protection during use.

– Hand hygiene must be performed before and after

donning and doffing eye or face protection.

– HCW should avoid touching the T zone, eyes,

nose, mouth during shift without performing hand

hygiene first!!

PPE Update

• National shortage of personal protective equipment,

specifically facemasks and N95s

– Follow PPE conservation recommendations and

optimize your facility’s supply of PPE in the event of

shortages

• Those out of supplies and in immediate need email

isdhdeplogistics@isdh.in.gov

#6

Resident Placement• Use the CDC home care guidance for residential apartment,

foster care, home based care. Private room is preferred for all

symptomatic if available.

– Home Care Instructions for Novel Coronavirus (COVID-19)

– Isolate resident to one room or section of the building, apartment to prevent

the spread of droplets.

– Cohort by keeping all sick in one location, Cohort supplies, and staff caring

for the sick.

• ONLY ESSENTIAL staff should go into the room of a

confirmed or presumed COVID-19 patient.

• Mask all care givers and resident when in direct contact to

prevent transmission.

• Assure all staff have ABHR at point of use.

– If used in pocket consider that pocket dirty and do not put cellphone or keys

in the same pocket

#7

If COVID-19 is suspected, based on

evaluation of the resident or prevalence of

COVID-19 in the community • Residents with known or suspected COVID-19 do not need to be placed into an

airborne infection isolation room (AIIR) but should ideally be placed in a private

room with their own bathroom.

• Recommend moving all COVID-19 residents to one area of building or

wing.

• Room sharing might be necessary if there are multiple residents with known or

suspected COVID-19 in the facility.

• As roommates of symptomatic residents might already be exposed, it is

generally not recommended to separate them in this scenario.

• Depending on your facility lay out and COVID-19 area ISDH is available to

discuss your individual needs.

• Facilities should notify the health department immediately and follow

– Interim Infection Prevention and Control Recommendations for Patients with

COVID-19 or Persons Under Investigation for COVID-19 in Healthcare

Settings which includes detailed information regarding recommended PPE.

Protect HCWLimit Risk

#7

#8

Protect Yourself Limit Risk

Protect Your FamilyLimit Risk

Keeping it safe! Scrubs

• HCW scrubs should be changed into street clothes

each day before leaving facility.

– HCW should perform hand washing upon entry to

the building before work and prior to exit after

changing into street cloths.

• HCW should refrain from wearing scrubs home or

the next day without being laundered, this

includes jackets.

Monitor Healthcare Workers

– Ensure HCW are encouraged to stay home

if they are ill with respiratory symptoms.

• Send all HCW home if they report with temp or

respiratory symptoms.

– Be aware of recommended work

restrictions and monitoring based on staff

exposure to COVID-19 patients.

– Advise employees to check for any signs of

illness before reporting to work each day

and notify their supervisor.

Return to Work Criteria for HCW with

Confirmed or Suspected COVID-19

Use one of the below strategies to determine when HCW may return to work in healthcare

settings

• Non-test-based strategy. Exclude from work until

– At least 3 days (72 hours) have passed since recovery defined as resolution of fever

without the use of fever-reducing medications and improvement in respiratory

symptoms (e.g., cough, shortness of breath); and,

– At least 7 days have passed since symptoms first appeared

• Test-based strategy. Exclude from work until

– Resolution of fever without the use of fever-reducing medications and

– Improvement in respiratory symptoms (e.g., cough, shortness of breath), and

– Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19

from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours

apart (total of two negative specimens)

• [1]. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens

for 2019 Novel Coronavirus (2019-nCoV).

• If HCP were never tested for COVID-19 but have an alternate diagnosis (e.g., tested

positive for influenza), criteria for return to work should be based on that diagnosis.

Food and Supplies

• Wash fresh foods as recommended, heating

food will reduce risk for possible virus

transmission on food

• Separate food from to go containers discarding

and putting in your clean

• Wash dishes and utensils using gloves and

hot water: Handle any non-disposable used

food service items with gloves and wash with hot

water or in a dishwasher.

• Clean hands after handling used food service

items.

#9

Food and Supplies

• Outside shipping boxes should have a

staging area.

• Remember to disinfect outer boxes wearing

gloves when transferring into the residents

home or facility.

• Perform HH

• Surface reminder for COVID transmission– Cardboard 24 hours

– Plastic > 72 hours

– Stainless Steel 48 hours

Infection Risk During Transitions

• Increase risk of transmission of COVID with transport

• Residents and patients should wear a facemask and transport team

#10

Believe that infection prevention is

everyone’s responsibility

Basic Infection Control Practices will keep

residents and HCW safe during COVID 19

Contact InformationJennifer Spivey MSN, RN,

CNOR, CIC, FAPIC

Infection Preventionist

Infectious Disease Epidemiology

Epidemiology Resource Center

Indiana State Department of

Health

Work: 317-262-0639

Email: JSpivey@isdh.in.gov

Any Questions?